Robotic-assisted, laparoscopic, and open incisional hernia repair: early outcomes from the Prospective Hernia Study.

PURPOSE: To provide a comparative analysis of short-term outcomes after open, laparoscopic, and robotic-assisted (RAS) ventral incisional hernia (VIH) repairs that include subject-reported pain medication usage and hernia-related quality of life (QOL). METHODS: Subjects were ≥ 18 years old and underwent elective open, laparoscopic or RAS VIH repair without myofascial release. Perioperative clinical outcomes through 30 days were analyzed as were prescription pain medication use and subject-reported responses to the HerQLes Abdominal QOL questionnaire. Observed differences in baseline characteristics were controlled using a weighted propensity score analysis to obviate potential selection bias (inverse probability of treatment weighting, IPTW). A p value < 0.05 was considered statistically significant. RESULTS: Three hundred and seventy-one subjects (RAS, n = 159; open, n = 130; laparoscopic, n = 82) were enrolled in the study across 17 medical institutions within the United States. Operative times were significantly different between the RAS and laparoscopic groups (126.2 vs 57.2, respectively; p < 0.001). Mean length of stay was comparable for RAS vs laparoscopic (1.4 ± 1.0 vs 1.4 ± 1.1, respectively; p = 0.623) and differed for the RAS vs open groups (1.4 ± 1.0 vs 2.0 ± 1.9, respectively; p < 0.001). Conversion rates differed between RAS and laparoscopic groups (0.6% vs 4.9%; p = 0.004). The number of subjects reporting the need to take prescription pain medication through the 2-4 weeks visit differed between RAS vs open (65.2% vs 79.8%; p < 0.001) and RAS vs laparoscopic (65.2% vs 78.75%; p < 0.001). For those taking prescription pain medication, the mean number of pills taken was comparable for RAS vs open (23.3 vs 20.4; p = 0.079) and RAS vs laparoscopic (23.3 vs 23.3; p = 0.786). Times to return to normal activities and to work, complication rates and HerQLes QOL scores were comparable for the RAS vs open and RAS vs laparoscopic groups. The reoperation rate within 30 days post-procedure was comparable for RAS vs laparoscopic (0.6% vs 0%; p = 0.296) and differed for RAS vs open (0.6% vs 3.1%; p = 0.038). CONCLUSIONS: Short-term outcomes indicate that open, laparoscopic, and robotic-assisted approaches are effective surgical approaches to VIH repair; however, each repair technique may demonstrate advantages in terms of clinical outcomes. Observed differences in the RAS vs laparoscopic comparison are longer operative time and lower conversion rate in the RAS group. Observed differences in the RAS vs open comparison are shorter LOS and lower reoperation rate through 30 days in the RAS group. The operative time in the RAS vs open comparison is similar. The number of subjects requiring the use of prescription pain medication favored the RAS group in both comparisons; however, among subjects reporting a need for pain medication, there was no difference in the number of prescription pain medication pills taken. While the study adds to the body of evidence evaluating the open, laparoscopic, and RAS approaches, future controlled studies are needed to better understand pain and QOL outcomes related to incisional hernia repair. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02715622.

The continuing challenge of Fournier's gangrene in the 1990s.

Fournier's disease is a potentially fatal acute, gangrenous infection of the scrotum, penis, or perineum associated with a synergistic bacterial infection of the subcutaneous fat and superficial fascia. Thrombosis of small subcutaneous arterioles with resultant ischemia contributes to the rapid extension of the infection. During a 12-year period, the clinical and operative records of 14 patients with Fournier's gangrene were analyzed. All patients were treated with broad spectrum antibiotics and serial surgical debridements. Nine patients had polymicrobial isolates from the initial wound culture; two patients had Group A Streptococcus species as the sole isolate. The etiology of the infection was identified in 12 patients. Five patients died for an overall mortality of 38 per cent. The mean age of survivors was 51 years compared with 75 years for nonsurvivors (P<0.05). The last six patients in this series survived. The mean hospital stay was 29 days. Four patients (31%) had a prior history of diabetes; however, 11 patients (85%) had elevated serum glucose levels (>120 mg/dL) on admission. All patients were hypoalbuminemic on admission. Survivors had an average serum creatinine on admission of 1.28 mg/dL compared with 3.1 mg/dL for nonsurvivors. Although supportive care is required in these patients, the mainstay for treatment of Fournier's gangrene entails an aggressive approach with frequent and extensive soft tissue debridements to control the invasive nature of the infection with delayed wound coverage once the infection has been controlled. Elderly patients with evidence of renal dysfunction on admission have a poor prognosis despite aggressive therapy.

May-Thurner syndrome: management by endovascular surgical techniques.

May-Thurner syndrome is a condition in which there is impaired venous return due to compression of the left common iliac vein by the overlying right common iliac artery. The impedance of flow occurs both by the compressive force of the artery against the vein and by resultant intraluminal web formation inside the vein. Because of the mechanical nature of the obstruction, conservative management of these patients has resulted in poor outcomes. Typically, operative therapy is recommended and perused via various approaches. We have recently treated a 15-year-old patient with this disorder utilizing endovascular surgical techniques with an excellent outcome. A 1-year follow-up is presented.